A 35 yo male presents with right shoulder pain.  He was riding up a steep hill in a tractor when the tractor rolled backwards.  He has an intact radial pulse and the distal motor and sensory exam are intact in the right upper extremity.  There are no obvious deformities.  An x-ray of the right shoulder is shown below.  What's the diagnosis?  Scroll down for answer.

Answer: Right scapula fracture

• Presents with localized tenderness over scapula and arm held in adduction
• Injury due to high energy mechanism
• Suspect concomitant injuries
• Associated with ipsilateral lung (PTX, pulmonary contusion, rib fracture) and shoulder girdle injuries
• Obtin CT chest, CT scapula
• Most treated non-operatively with sling, ice, analgesics, early range of motion exercises and orthopedic referral
• Operative cases involve a glenoid fracutre, acromion fracture with rotator cuff tear

Reference:

Bjoernsen L, Ebinger A. Shoulder and Humerus Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY